Part 1: The Challenge
Cervical cancer remains a profound global health inequity. Around 604,000 women were diagnosed in 2024 and about 280,000 died, with the highest incidence and mortality rates concentrated in low- and middle-income countries. HPV vaccination offers highly effective protection, and the World Health Organization has set a target for 90% of girls to be vaccinated by age 15.
Reaching adolescent girls brings its own communication demands. VillageReach and BCL’s Peer-to-Peer Learning to Improve HPV Vaccine Coverage project in Nigeria and Mozambique is helping health workers and community representatives develop locally relevant responses to the challenges surrounding HPV vaccination. Questions about the vaccine often circulate through families, schools and social networks before a girl reaches a vaccination site. In Mozambique, VillageReach documented fears that HPV vaccination could cause infertility; community discussions in Nigeria surfaced the same concern directly from caregivers. WHO has found that misinformation and rumors about HPV vaccine safety can damage confidence and reduce acceptance, making timely, credible communication central to successful delivery.
Health workforce pressures, like health worker shortages and uneven distribution, make that communication harder to sustain. Extended community outreach and repeated conversations about safety, eligibility and concerns require additional time, and trusted people who already have relationships with girls and their families can expand the reach of accurate information within the community.
The educational cards developed in collaboration with Stanford Digital Medic through the Peer-to-Peer Learning to Improve HPV Vaccine Coverage project give those conversations a practical tool. They are designed for use by people including teachers, adolescent girls, caregivers, community leaders and health workers, with imagery and messages shaped for the communities where they will be used. Laminated, ring-bound and poster formats support repeated use during discussions and allows the materials to remain useful over time, extending a familiar form of health education into something made for dialogue, shared learning and the people who already carry trust within their communities.
This special, interactive report outlines the process and theory behind the educational cards’ development, starting with what matters most: what we heard from adolescent girls (all quotes below were taken from exit surveys conducted in Nigeria):
Questions and concerns raised about HPV vaccination
“Why can’t boys take the vaccine?”
“I hope it doesn’t have side effects maybe now or in future?”
“Will the injection make me not to have children. Will it delay when I want to have children?”
“They said is for preventing us for not to have pregnancy when we got married.”
“What can happen to me after I take the vaccine?”
“If I get the vaccine will it make me want to eat too much?”
“Why do I need to get the injection?”
“I don't know the reason why it’s given to only girls of my age group.”
“How painful will the injection be?”
“What is the vaccine used for?”
“What causes papilloma disease and how do you know that you have the disease?”
“How many doses am I going to take and the duration?”
“What will happen to me if I decide not to be vaccinated?”
“I’m afraid of what the rumors said that she might not give birth later.”
“[I want to know] if girls that have taken the vaccine will give birth to children?”
“I need more explanation about how the vaccine works.”
“[I want to know] what HPV means, the cause, and the symptoms.”
“[I want to know] how the vaccine works and duration?”
“Because [the vaccine] was produced from the west. I think it’s to reduce the population of black Africans.”
“I wish they explained side effects of the vaccine.”
Part 2: Starting with Listening
The project began by asking frontline health workers and community health workers what they were encountering as HPV vaccination moved into communities. In dedicated workshops, team members described the situations they saw repeatedly, the questions they struggled to answer and the practical realities shaping vaccination uptake. Their experiences became the starting point for understanding which challenges deserved deeper attention.
Some involved trust and information. In FCT, Nigeria, 85% of surveyed caregivers had received HPV vaccine information from health workers, while teachers reached 34% and religious or community leaders 31%. Girls commonly relied on health workers and teachers, and community leaders became especially important for reaching girls outside school. Many girls wanted more opportunities to ask questions about the vaccine.
Other barriers became clearer when participants mapped vaccination from the perspective of the people experiencing it. In Mozambique, health workers described weak community mobilization, transportation constraints and limited time for outreach. Teachers could have considerable influence because of the time they spent with adolescent girls, while gaps in HPV knowledge sometimes limited their ability to answer questions confidently.
Personas and journey maps, like Maria’s below, helped turn those observations into lived experiences. Maria, a nine-year-old girl in Sussundenga, wants to become a nurse and looks to people close to her for guidance. Her path toward vaccination can involve fear of needles, questions about safety, parental permission, transport costs and a long journey to the health facility. Even after reaching care, she may leave with parts of the experience she still does not fully understand.
Maria’s journey
From questions at home to vaccination at the health facility
Maria wants to get vaccinated, but distance, uncertainty and family decision-making shape whether that can happen. Maria’s experience shows how information, family support, travel and quality of care all shape whether a girl receives the HPV vaccine.
The Learning Exchange teams used insights like these to decide which HPV vaccination challenges should move forward into the participatory ideation workshops that followed.
Part 3: Designing With Communities
The challenges prioritized by the Learning Exchange teams became the starting points for participatory ideation workshops in Nigeria and Mozambique. Community representatives, caregivers, health workers and other local stakeholders worked together to explore possible responses, drawing on their own experience of how information moved through families, schools, health facilities and community networks. This was central to the Learning Exchange approach: participants were expected to develop and test contextualized solutions grounded in the communities where they worked.
The discussions revealed how much context matters in HPV communication. Participants brought forward the rumors circulating locally, the people families trusted, religious and cultural considerations, and the practical difficulties of explaining health information across different literacy levels. Earlier work in Nigeria had also shown variation between states in how people encountered and trusted HPV information, including the roles played by teachers, religious leaders and community leaders.
Across the different settings, many of the underlying information needs were similar. Girls and caregivers wanted clear explanations of cervical cancer and HPV vaccination, reassurance around safety and fertility concerns, and information they could understand and discuss with people they trusted.
Among the solutions generated through the workshops was a need for culturally appropriate educational materials in local languages, using visual illustrations suited to the literacy levels and cultural context of adolescents and caregivers. This solution pathway became the starting point for the educational cards. The cards were developed in response to ideas generated through participatory design rather than as a predetermined communication intervention.
The workshops also helped define what those materials would need to do. They had to support conversations with adolescent girls and caregivers while being practical for a wide range of people to use, including health workers, teachers, community and religious leaders, model mothers and girl peer educators. The core HPV information was largely consistent across locations, while language, local concerns and the context in which the cards would be used required room for adaptation.
With those requirements in place, VillageReach and Stanford Digital Medic began translating the emerging concept into messages, layouts and artwork.
Part 4: Early Design Exploration
Visual design choices in health communication carry enormous weight. They can either build trust and knowledge or inadvertently sow fear and confusion. For the HPV educational cards, Digital Medic’s design decisions were informed by local feedback at key stages, translating what had been learned through the participatory process into instructional materials that could support conversations with varied audiences across Mozambique and Nigeria.
Core design principles were established from the outset: the cards needed to present accurate and actionable information in a clear, highly visual, and uplifting style. A vibrant color palette reflecting hues found in the local attire and landscape was used to evoke visual familiarity for the target audience. Images emphasizing the benefits of vaccination and featuring people with calm and confident expressions further underscored the positive tone.
Primary colors
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Neutral colors
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Skin tones
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Accent colors
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Central to the visual design was the shield motif, a symbol of protection that could be understood across cultures and literacy levels. This shield became the visual anchor throughout all the cards, connecting HPV vaccination to lifelong protection against cervical cancer. To support this message of protection, the color yellow was used strategically in the shield itself, in the dress of the girl receiving her vaccine and in the attire of women representing her protected future.
Iteration and listening were essential to developing a visual language and layouts that clearly communicated the core messages. Early drafts combined rough sketches, repurposed artwork from previous projects and AI-generated images—an intentionally scrappy approach that allowed rapid prototyping and faster feedback cycles with the reviewers in Mozambique and Nigeria. Their feedback revealed important insights that shaped the designs to promote clarity and confidence.
One notable example of this iterative process was the design of the first card (back and front), which focused on foundational concepts, including what HPV is, how it spreads, its connection to cervical cancer, the lifelong protection that vaccination before exposure provides, and who should get the vaccine and when. Early feedback led to the reorganization and simplification of the layout to strengthen these messages.
Design evolution
Early concepts depicted the HPV virus being warded off by a girl holding a shield marked with a vaccine symbol. The girl’s shadow cast a series of silhouettes that depicted not only her current age but also future stages of life, conveying the long-lasting effects. Layered over these silhouettes were anatomical images of the uterus to indicate the body part being protected. Local reviewers found this approach potentially confusing.
Design evolution
Early drafts also included a cartoon showing the vaccine teaching the body’s immune cells to recognize and target HPV. This visual was removed because it was unclear and ultimately unnecessary for learners to make informed choices about vaccination. Instead, a thought bubble showed fully rendered images of the girl at different life stages: teenager, young woman, mother with her own baby, middle-aged and elderly, alongside the timeline, to strengthen the message of lifelong protection.
Other feedback led to revisions to alleviate fear, including subtle changes to the facial expression of the girl receiving the vaccine to look less nervous, reducing the size of the syringe to be more accurate and less alarming to viewers, and removing visuals of rare adverse events and replacing them with a verbal message about when to seek care.
Part 5: Refinement and Localization
Once the messages, layouts and draft artwork were established, the Digital Medic team transformed the prototypes into deployable tools in the four languages: English, Portuguese, Hausa and Igbo. This involved producing full-color images using the vibrant palette described above and further refining the designs to resonate with the specific communities that would use them.
Feedback on attire and hairstyles informed the final artwork, including changing the girl’s athletic shoes to sandals, shortening her braids, and adding head scarves for women and girls in the Hausa version used in northern Nigeria.
Messages addressing myths were also tailored to specific audiences, focusing only on myths circulating in those communities and avoiding the introduction of new myths. Additionally, a poster layout was created for display in schools and health facilities in Nigeria. The poster summarized the most essential messages from the cards.
The collaborative, human-centered design process used to create the HPV educational cards was essential for their success. Each iteration moved the cards closer to their ultimate purpose: building trust, correcting myths, and equipping communities with clear, actionable and culturally appropriate information about HPV vaccination.
Part 6: From Design to Use
The finished educational cards were designed to support conversation. An accompanying messaging guide helps educators and mobilizers connect each visual with accurate HPV information and adapt how they explain it for adolescent girls, caregivers and other community members. Health workers, community health workers, teachers, model mothers and girl peer educators receive training on both the content and the facilitation approaches that accompany them, so they can confidently use the cards during health talks, household visits and other community activities, creating space for questions and discussion with people communities already know and trust.
Mozambique
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Nigeria
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This approach is being applied as part of wider community-led efforts to strengthen HPV demand generation. Feedback from the people using the cards remains part of the process, helping identify what works, where conversations remain difficult and where the accompanying guidance may need adjustment.
The usefulness of the approach outlined here extends beyond HPV vaccination. Our process began with frontline experience, brought communities into defining and prioritizing problems, generated possible responses collaboratively and used repeated feedback to develop one of those ideas into a practical tool. It offers a replicable model for health communication that combines evidence, adaptability, trusted messengers and continued learning from implementation.